Get Acclaris Fsa Reimbursement Form - Bank Of America

Completing the Acclaris FSA Reimbursement Form online can facilitate faster processing of your claims. This guide provides clear, step-by-step instructions to help you accurately fill out the form and submit your reimbursement request.

Follow the steps to complete the reimbursement form effectively.

1. Click 'Get Form' button to retrieve the Acclaris FSA Reimbursement Form and open it in your editing tool.
2. Enter your basic details: Fill in your name, employee ID or Social Security Number, daytime phone number, email address, and employer name in the required fields.
3. Complete the health care reimbursement claim section: List the date of service, type of service or product, the name and relationship of the individual receiving the service, and the amount claimed for each entry. Make sure to attach any necessary bills, receipts, or Explanation of Benefits that verify these details.
4. Calculate the total health care amount requested by summing up all claimed amounts in the health care section.
5. Fill out the dependent care reimbursement claim section: Record the date of service, dependent’s name, relationship, and date of birth, along with the provider's name, address, tax ID or SSN, and the amount for each entry. Ensure that appropriate documentation is attached, or have your dependent care provider sign below if receipts are not available.
6. Calculate the total dependent care amount requested, verifying all details are accurate.
7. Read and acknowledge the certification statements regarding reimbursement compliance and checking the box if you do not have online access, ensuring you provide your email.
8. Finally, sign and date the form as the participant to validate the claims made.
9. After completing the form, you can save changes, download it for printing, or share it as required for submission.

Complete your Acclaris FSA Reimbursement Form online today to ensure a smooth reimbursement process.